Attachment 44 -- MPC Hospital Respondent Materials - Patient Records - Fax Version

Contact Group ID#: «PROVIDER_ID»

HTTP://WWW.MEPS.AHRQ.GOV
«DATE»

«CONTACT_NAME»

MEDICAL RECORDS DEPARTMENT

«FAX_NUMBER»

Record File Number: «RECORD_FILE_NUMBER»

Account File Number: «ACCOUNT_FILE_NUMBER»

Total Pages (including cover sheet): «TOTAL_PAGES»  

Thank you for taking the time to speak with me earlier, and agreeing to help us with this research study.

This package contains the study information and signed patient authorization forms that I said I would send to you.

These forms were signed by your patients who are actively participating in this research study. These signed forms allow us to contact you for a few pieces of information about the medical events that you provided to these patients in 2010.

FOR EACH PATIENT EVENT WE NEED THE FOLLOWING:

• DATE OF SERVICE

• SERVICES PROVIDED

• DIAGNOSES/CONDITIONS

• CONTACTING INFORMATION FOR SEPARATELY BILLING DOCTORS

«SPECIAL_COMMENT»

TO FAX RECORDS:

«TOLL_FAX_NUMBER»

TO MAIL RECORDS:

«MEPS_MAIL_ADDRESS»

TO PROVIDE DATA VIA PHONE:

«TOLL_PHONE_NUMBER»

This fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

Notice - Public reporting burden for this collection of information is estimated to average 5 minutes per patient. Any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden should be sent to: AHRQ/MEPS Reports Clearance Officer, John M. Eisenberg Building, Room 5036, 540 Gaither Road, Rockville, MD 20850, Attention: PRA Paperwork Reduction Project (0935-0118). (Please do not send patient data to this address as it will delay data processing.)

	DEPARTMENT OF HEALTH & HUMAN SERVICES Agency for Healthcare Research and Quality
	Contact Group ID#: «PROVIDER_ID»

Dear «PROVIDER_NAME»:

We understand that one of our data collection specialists has talked to you about the Medical Provider Component of the Medical Expenditure Panel Survey. We are appreciative of the contributions you and your hospital are providing to this important study that is being conducted for the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), both part of the U.S. Department of Health and Human Services. We wanted to take this opportunity to tell you more about the study.

The objective of the study is to provide accurate information to government policymakers and private researchers about the rapidly changing health care situation in this country. To accomplish this goal, we have collected data from a cross-section of American households on how they used and paid for health care during 2010. With the written permission of members of these households, we are now contacting their medical providers to determine the actual dates of service, the diagnoses/conditions, the services provided, the amount that was charged, the amount that was paid, and the sources of payment. One or more of your patients have given us written authorization to request this information from your medical and billing records.

The study materials enclosed with this letter include a list of your patients who have agreed to participate in the survey and an authorization form for each patient.

This survey is authorized by section 902(a) of the Public Health Service Act [42 U.S.C. 299a]. Participation is voluntary, but we are depending on you to help us toward a more complete understanding of the nation’s health care. The client information we obtain will be used for research purposes only and will be released publicly only in summary form in which establishments or individuals cannot be identified. The confidentiality of client information is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. Information that could identify an client or establishment will not be disclosed unless that client or establishment has consented to such a disclosure.

A Data Collection Specialist from our contractors, RTI International (RTI) and Social and Scientific Systems, Inc. (SSS), will call shortly after you have received these materials to see if you have any questions and to arrange for the collection of these data. If you have questions about the forms or procedures, call RTI-SSS, toll-free at «TOLL_PHONE_NUMBER».

Sincerely,

Carolyn Clancy, M.D. Director Agency for Healthcare Research and Quality	Edward J. Sondik, Ph.D. Director National Center for Health Statistics Centers for Disease Control and Prevention

Contact Group ID#: «PROVIDER_ID»

Instructions (Medical Records)

«INSTRUCTION»

«PROVIDER_ID»:

«PROVIDER_NAME»:

Thank you for taking the time to provide this medical records information. We realize your time is valuable and limited. If you would like to contact us directly, please call «TOLL_PHONE_NUMBER».

The patient(s) listed below have given us written authorization to contact you and request information from your records. Copies of the signed authorization forms are included in this fax.

Step 1: Please Locate Medical Records for Each Patient in Your Records: For each patient included in the Confidential Patient Check List, please locate the following information on all services each patient received between January 1, 2010 and December 31, 2010.

• Date(s) of service

• Services provided

• Diagnoses/conditions

• Names, specialties and telephone numbers (if available) for practitioners who provided service to the patient in the hospital but billed separately

Step 2: Please Record Outcome on the Confidential Patient Check List: Please indicate whether you were able to locate the 2010 patient records, if you were able to locate the patient but there were no 2010 records, or if the individual is not a patient, by checking the appropriate box next to the patient in the Confidential Patient Check List.

Step 3: Please Provide Information via Fax or Mail: Please assemble the information for all patients in the Confidential Patient Check List and fax or mail it to us, using the Fax Cover Sheet or Mail Return Form. Please include the completed Confidential Patient Check List, with the appropriate box checked for each patient, in the package. If we do not hear from you, a data collection specialist will contact you to arrange for the collection of these data. If you would prefer to provide the medical records information over the telephone we can arrange for the collection of these data at your convenience. Please call «TOLL_PHONE_NUMBER».

Contact Group ID#: «PROVIDER_ID»

Instructions (Continued)

Please use the Confidential Patient Check List on the following page as a way to record the outcome of locating each patient record in your files, and include it when faxing or mailing your materials. If you choose to provide the medical billing information over the telephone, you may use this list as a reference tool for recording the outcome of locating each patient record in your files.

  REMINDER:  
IF RETURNING RECORDS BY FAX OR MAIL,
PLEASE INCLUDE THIS CHECK LIST FORM.

If faxing material, please fax to: «TOLL_FAX_NUMBER»

If mailing material, please send to: MEPS-Medical Provider Component Director «MEPS_MAIL_ADDRESS»

Contact Group ID#: «PROVIDER_ID»

Confidential Patient Check List

«PROVIDER_ID»

«PROVIDER_NAME»

		CHECK ONE FOR EACH PATIENT:
	Patient Name	Date of Birth	Gender	2010 Patient Records Located	Found Patient No 2010 Records	Is Not A Patient
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»
«N»	«PATIENT_NAME»	«DOB»	«GEN»	«CB»	«CB»	«CB»

Contact Group ID#: «PROVIDER_ID»

Questions and Answers

What is the Medical Expenditure Panel Survey (MEPS)?

MEPS is a nationwide research study conducted to learn more about the health care services people use, the charges for those services and the sources that pay for them. MEPS is conducted annually by the U.S. Department of Health and Human Services through the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. Major components of MEPS include surveys of:

• A nationally representative sample of households;

• Hospitals, physicians, home care providers, and pharmacies reported by the household participants; and

• Providers of health insurance.

MEPS is the most complete source of data available on health care use and expenses in the United States and is used by government policymakers and private researchers.

How are hospitals chosen?

Hospitals and/or facilities associated with a hospital were named by respondents in the household data collection as sources of care during 2010. The patients we are asking about signed HIPAA-compliant forms authorizing and requesting you to release the information sought by the study.

Why should this hospital participate?

Hospital expenditures are a major component of health care costs. The information that you supply will supplement that given by your patient and help us build a more complete picture of health care expenditures for respondents in our study. Your patients have asked specifically for your help by signing the authorization form.

What information is needed?
For each of the patients on the enclosed list, we need information about their hospital events. For each date of service in 2010, we need:

• Date of service

• Services provided (CPT-4, DRG, revenue code, HCPCS, or description)

• Total charge

• Payment sources and amounts

• Diagnoses/conditions

• Information on the practitioners who provided service to the patient in the hospital but billed separately.

How do I know the information will be kept confidential?

The confidentiality of data collected for MEPS is protected by Federal law under Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. No information that could identify an individual or establishment will be disclosed unless that individual or establishment has consented to such a disclosure.

Personal identifying information such as names or addresses are removed before information from the study is made available to researchers. Findings are published in statistical summaries and tables and micro-data is released on “public use” data files.

Who is collecting this data?

The U.S. Department of Health and Human Services has chosen has chosen RTI International (RTI) and Social and Scientific Systems, Inc. (SSS) to administer the study. A professionally trained data collection specialist from RTI-SSS will contact each hospital.

What questions will the data collected answer?

MEPS data provide answers to many important questions. For example:

• How much of hospital costs are covered
  by insurance?

• How much do people pay out of pocket for their
  hospital care?

• What conditions are being treated in hospitals?

• What types of health care services are people
  receiving from hospitals?

Any further questions?

Please call toll-free, at
«TOLL_PHONE_NUMBER». For direct access to information
about MEPS, go to
http://www.MEPS.AHRQ.gov.

Contact Group ID#: «PROVIDER_ID»

Fax Cover Sheet or Mail Return Form

TO	Data Collection Specialist
Fax	«TOLL_FAX_NUMBER»
Phone	«TOLL_PHONE_NUMBER»
From
Date
Total Pages (including cover sheet)

If mailing material, please include this Fax Cover Sheet or Mail Return Form in your envelope. Please remember to include the Confidential Patient Check List. Thank you.

Please send to:

M



EPS-Medical Provider Component Director

«MEPS_MAIL_ADDRESS»

REFERENCE:

«PROVIDER_NAME»

«PROJECT_CHARGE_NUMBER»

Provider Name: «PROVIDER_NAME»

This fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

35027401